Child's Personal Data Sheet - Arkansas Department of Human ...

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INCIDENT REPORT To be filled out as soon as possible on the day of the incident by the person witnessing the occurrence. Child's name Parent/Guardian's Name Person in Charge Date of Incident Time of Incident Describe Incident (What happened) Place or Incident (Area) Name of Witnesses: Who was notified (Parent/Relative), When, Date, Hour: Describe Actions taken by Staff: Could this incident have been avoided? If yes, then how? Staff Comments Signature & Date (Staff Completing Report) Signature Parent/Guardian DCC 529 Ρ(8/97) TECHNICAL ASSISTANCE
INJURY LOG This form is to be used to log injuries that occur in the facility in order to determine if there are areas in the center where more injuries occur than other places in the center. Date Time of injury Staff reporting Child's Name Child Age What happened to cause injury? Where did it happen? Suggested prevention steps Have steps been taken?/Date Date Time of injury Staff reporting Child's Name Child Age What happened to cause injury? Where did it happen? Suggested prevention steps Have steps been taken?/Date Date Time of injury Staff reporting Child's Name Child Age What happened to cause injury? Where did it happen? Suggested prevention steps Have steps been taken?/Date Date Time of injury Staff reporting Child's Name Child Age What happened to cause injury? Where did it happen? Suggested prevention steps Have steps been taken?/Date Date Time of injury Staff reporting Child's Name Child Age What happened to cause injury? Where did it happen? Suggested prevention steps Have steps been taken?/Date Date Time of injury Staff reporting Child's Name Child Age What happened to cause injury? Where did it happen? Suggested prevention steps Have steps been taken?/Date DCC 525 Ρ(8/97) TECHNICAL ASSISTANCE
Page 1 and 2: Child's Personal Data Sheet 1. Name
Page 3 and 4: ACCIDENT REPORT To be filled out as
Page 5 and 6: EMERGENCY DRILL RECORD Date Smoke D
Page 7 and 8: Do you have documentation of an ann
Page 9 and 10: Program Enrichment Individual Regis
Page 11: IMMUNIZATION CONTROL FORM Name of F
Page 15 and 16: Staff Acknowledgement of Orientatio
Page 17 and 18: Staff/Child Ratio Worksheet Name of
Page 19 and 20: Transportation Roster Facility Dire
Page 21 and 22: Daily Schedule Please list the time
Page 23 and 24: Daily Sign in Sheet Facility: Today

Child's Personal Data Sheet - Arkansas Department of Human ...

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